Provider Demographics
NPI:1730789967
Name:KOTASKA, NICOLE RENEE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:KOTASKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5903 WESSEX CT
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:TX
Mailing Address - Zip Code:75002-5455
Mailing Address - Country:US
Mailing Address - Phone:214-563-5230
Mailing Address - Fax:
Practice Address - Street 1:2662 W LUCAS RD
Practice Address - Street 2:
Practice Address - City:LUCAS
Practice Address - State:TX
Practice Address - Zip Code:75002-7513
Practice Address - Country:US
Practice Address - Phone:469-675-8110
Practice Address - Fax:469-675-8528
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist